Which is Better - A Standalone Ventilation or Perfusion Scan or Combined Imaging to Predict Postoperative FEV1 in One Seconds in Patients Posted for Lung Surgeries with Borderline Pulmonary Reserve.

INTRODUCTION: Forced expiratory volume in one second (FEV1) is an independent predictor for respiratory morbidity. Reports are varied and controversial substantiating the use of either lung perfusion (Q) or ventilation (V) scintigraphy as a single stage investigation to predict postoperative (ppo) FEV1 in patients scheduled for lung resection surgeries. It is said that there is no additional benefit by performing both V/Q scan. As per one of the recommendations, no further respiratory function tests are required for a lobectomy if the postbronchodilator FEV1 is >1.5 l. We wanted to study the ppo FEV1 in patients with FEV1 of <1.5 L scheduled for lung surgeries. Being a high-risk population, we wanted to assess (a) whether the ppo changes by this combined V/Q imaging and (b) whether the incidence of respiratory complication in the postoperative setting of this subgroup is different, (c) and study the short- and long-term clinical outcome. MATERIALS AND METHODS: Fifty-two high-risk patients (with comorbidities) and borderline preoperative FEV1 of 1.5 L or less planned for lung resection were enroled in this prospective study. V and Q scans were performed, and tracer uptake percentage was tabulated. RESULTS: Tracer uptake in each lung was quantitated. Manual method of ROI drawing is preferred in high risk patients with reduced pulmonary reserve over the automatic method. Based on uptake patterns by V/Q scans, 4 different types of patterns were tabulated. Eighty-eight percentage of centrally placed tumors showed the difference in uptake patterns. Chronic obstructive pulmonary disease patients usually showed more modest ventilatory defects (categorised as type 2 or 3). Lung tumours produce erratic uptake patterns (Type 4) which depend heavily on their location and extent. The range of FEV1 predicted was 0.6-1.38 L/min. CONCLUSION: We recommend that combined imaging should be performed in patients with borderline pulmonary reserve to derive the benefit of surgery as it provides a realistic ppo FEV1 in patients with moderate to severely damaged lung. Centrally placed hilar or bronchial tumors (even those <2 cm in size), produce discrepancies in V/Q distribution pattern. Patient who was thought ineligible for surgery due to low baseline FEV1 may be actually be operable by this combined imaging if uptake pattern is better in V or Q scan with a good outcome. Accurate estimation of postop FEV1 in fact helps the surgical team to implement measures to prepare high risk patients to reduce postoperative complications, enable faster weaning from ventilatory support and ensure favourable prognosis.

Radioiodine as an adjuvant therapy and its role in follow-up of differentiated thyroid cancer.

Papillary and follicular cancers of thyroid are the most common varieties of differentiated thyroid cancers exhibiting excellent long-term prognosis when carefully managed. Being a slow-growing malignancy, guidelines exist on the staging, preoperative risk stratification, and management of these cancers to increase the overall survival of these patients. Radioactive iodine has a central role in differentiated thyroid malignancies. It has the same physical properties as stable iodine, thus both normal and malignant thyrocytes cannot differentiate radioactive from stable iodine. Differentiated thyroid carcinoma (DTC) cells concentrate cytocidal amounts of Iodine -131 (131 I) by trapping (the function of the sodium iodine symporter, or NIS) and organifying the iodide ion to produce levothyroxine and triiodothyronine. We shall discuss the role of radioiodine in the management and followup of DTC patients.

Primary peripheral neurolymphomatosis mimicking synovial sarcoma: FDG PETCT to the rescue.

Our understanding of the association between synovial sarcoma and peripheral neurolymphomatosis is limited to a few case reports in literature. Delay in diagnosis or misdiagnosis is possible due to its insidious onset and varied presentation compounded by non-specific imaging findings. Needle biopsy also may not be confirmatory especially, in cases of biphasic sarcoma as in our case, and it may be necessary to proceed to open biopsy. Here, is a case of a non-tender right calf muscle mass, which was reported as biphasic synovial sarcoma by FNAC. Positron emission tomography computed tomography-computed tomography (PETCT) showed right sciatic nerve involvement and multiple infra diaphragmatic lymph nodal lesions. Intensity of (18)F FDG ((18)Flourine labeled fluro de oxy glucose) uptake and the infra diaphragmatic lymph nodal lesions distribution, was more in favour of a lymphoma diagnosis rather than a sarcoma, (which are usually low metabolically active tumors). Thus, this case highlights the usefulness of FDG PETCT in arriving at a diagnosis in the background of indeterminate clinicopathological and radiologic findings.

Current practice and recommendation for presurgical cardiac evaluation in patients undergoing noncardiac surgeries.

The increasing number of patients with coronary artery disease (CAD) undergoing major noncardiac surgery justifies guidelines concerning preoperative cardiac evaluation. This is compounded by increasing chances for a volatile perioperative period if the underlying cardiac problems are left uncorrected prior to major noncardiac surgeries. Preoperative cardiac evaluation requires the clinician to assess the patient's probability to have CAD, severity and stability of CAD, placing these in perspective regarding the likelihood of a perioperative cardiac complication based on the planned surgical procedure. Coronary events like new onset ischemia, infarction, or revascularization, induce a high-risk period of 6 weeks, and an intermediate-risk period of 3 months before performing noncardiac surgery. This delay is unwarranted in cases where surgery is the mainstay of treatment. The objective of this review is to offer a comprehensive algorithm in the preoperative assessment of patients undergoing noncardiac surgery and highlight the importance of myocardial perfusion imaging in risk stratifying these patients.

Multilocular disseminated tarlov cysts: importance of imaging.

With technological advancements and wider availability of multimodality imaging, incidental lesions are frequently identified in patients undergoing various imaging studies. We report here a case of multiloculated disseminated perineural or Tarlov cysts (TCs). The primary aim of our study was to (1) provide a comprehensive review of the clinical, imaging and histopathological features of TCs (2) to draw attention to the fact that multiple lumbo-sacral and dorsal TCs can produce nerve injuries and serious movement disturbances (3) to document the usefulness of the magnetic resonance imaging (MRI) and bone scan in noninvasive diagnosis and guiding management in such cases. These cysts are clearly identified by MR and computerized tomography imaging of the lumbosacral spine. However, there are no reports on the scintigraphic findings of TCs in literature. TCs are typically benign, asymptomatic lesions that can simply be monitored. Until date, no consensus exists about the best surgical strategy to be followed for their management.

A case of VACTERL and non-VACTERL association without the "V and L".

VACTERL is a cluster of congenital malformations based on the non-random association of various congenital malformations in a single patient. Here "V" denotes vertebral defects or vascular anomalies (single umbilical artery), "A" anal atresia, "C" cardiac abnormalities, "TE" tracheoesophageal fistula, "R"renal (kidney) abnormalities and "L" for limb anomalies) It is called an association, rather than a syndrome because the complications are not pathogenetically related, tend to occur more frequently than expected and are thought to be linked to embryonic mesodermal defects. Studies have reported the coexistence of various other congenital malformations such as respiratory, cerebral anomalies, which are frequently referred as non-VACTERL-type of associations. Diagnosis of VACTERL association is done only when at least three of the above mentioned congenital malformations are identified in a patient. Although 80% of these cases have vertebral defects, our case is unique as patient does not have one of the commonest occuring association i.e., vertebral anomalies, but has all other associations and an additional non VACTERL brain anomaly, hitherto unreported in the literature. The other highlight of this case is although reports say that VACTERL babies with ipsilateral renal disorder have the same side limb defects, our case has a renal anomaly with no limb anomaly. Finally VACTERL and non VACTERL association was considered in our patient in view of ventricular septal defect, tracheo esophageal fistula, anal atresia, renal anomaly, seizure disorder and global developmental delay due to pontocerebellar hypoplasia.

A Case Report on Extruded Disc Acting as Buttonhole reventing Reduction in Traumatic Fracture and Lateral Dislocation of L1-l2 Vertebrae.

INTRODUCTION: There is a scanty literature support describing the incidence, mechanism of lateral dislocations of thoracolumbar spine and its management describing the reduction techniques. Hereby we present an interesting case of extruded disc acting as buttonhole preventing the reduction of lateral dislocation of L1-L2 vertebrae and this would be the first of its variety to be described ever in literature. CASE REPORT: A 30 year old female was referred to our hospital on post trauma day 7 with bilateral fascet fracture and lateral dislocation of L1-L2 vertebrae and fracture humerus on right arm following a road traffic accident. She presented with clinical signs consistent of cauda equina lesion. She underwent surgical reduction and TLIF L1-L2. On one year follow-up X-Rays showed maintenance of dorsolumbar saggital alignment without collapse. CONCLUSION: Dislocations of spine are three column injuries, are highly unstable requiring surgical stabilisation. Posterior instrumentation is the routinely followed technique to achieve reduction and for posterolateral fusion. In this case lateral dislocation was reduced only after removal of the laterally extruded disc. After complete discectomy TLIF was considered a good option for restoring disc space height and maintaining saggital balance.

Lymphoscintigraphy in the evaluation of limb edema.

Lymphedema is a chronic condition caused by ineffective lymphatic transport that results in edema and skin damage. Distinguishing lymphedema from other causes can be difficult. Lymphoscintigraphy is a simple and noninvasive functional test for the evaluation of the lymphatic system. (99m)Technetium-labeled sulfur colloid is injected intradermally at the interdigital web spaces of the upper/lower limbs. Once injected, the radiolabeled colloid particles travel through the superficial lymphatic channels. Thus, their lymphatic transport is monitored with dual-head gamma camera. The typical patterns of upper and lower limb lymphedema on lymphoscintigraphy are summarized in this section.

Unsuspected chylous ascites in an asymptomatic case of Rosai Dorfman disease.

Rosai-Dorfman disease, or sinus histiocytosis, first described in 1969, is a benign systemic disorder of histiocytes of unknown etiology characterized by massive lymphadenopathy. It predominantly involves the head and neck region, and is often associated with extranodal involvement. Patient presented to pulmonology with history of sudden onset dyspnea. Clinically and radiologically, the lungs were normal. D-dimer test was noncontributory. As the patient had a family history of lymphedema, lymphoscintigraphy was sought. We report the detection of an unsuspected case of Rosai-Dorfman disease by lower limb lymphoscintigraphy.

Scintigraphic assessment of patellar vascularity in total knee replacement surgeries following lateral release.

For a total knee replacement (TKR) to function well, the patella must track centrally in the trochlear groove. Lateral retinacular release (LR) is performed as an integral step in TKR to avoid maltracking. Patellar resurfacing and infra patellar fat pad excision are other small surgical procedures performed during TKR that can also easily deprive the patella of its vascularity. A three phase bone scan helps in the assessment of patellar vascularity. Literature review reveals a variable association (10-56%) of LR and patellar hypovascularity in Caucasians. OBJECTIVE: LR release done in TKR is known to compromise patellar viability, while its extent and severity is still debated. Our prospective study was undertaken to evaluate the effects of LR on patella along with other variables like patellar resurfacement, fat pad excision, patelloplasty on knees by 99mTechnetium labeled methylene diphosphonate (99mTc MDP) three phase bone scintigraphy (TBS). MATERIALS AND METHODS: 45 TKRs were done between Jan 05 and Jan 06. Of them, 15 patients (21 knees) of primary TKR were considered prospectively. Patients undergoing uni/bilateral TKR due to symptomatic knee osteoarthritis were only selected for this study. Pre- and immediate postoperative TBS was done with modified positioning of knee joints (adducted, externally rotated and flexed to 30°) to visualize patellae away from knee joint, which otherwise gets superimposed on the femoral condyles. A follow-up TBS at 8-10 weeks was done in patients showing immediate post-op patellar hypovascularity. RESULTS: 12/21 knees (57%) needed LR. Of these 12 knees, 8 (66%) showed hypovascularity; whereas 9 knees with no LR, 1 knee showed hypovascularity. All 9 knees (8 post LR+1 without LR) with hypovascularity underwent TBS again at 8-10 weeks and were found to show improvement in their vascularity status in all cases. CONCLUSION: Our study showed a higher incidence of LR in our population (57%). Association of LR and patellar ischemia was significant, about 16 times the risk. MDP bone scintigraphy is the only objective tool to quantify patellar vascularity. Overall 42.8% knees post-TKR had a transient patellar ischemia, and 38% of them were following LR. All of them recovered at 8-10 weeks postoperatively.

PET/CT in the evaluation of anti-NMDA-receptor encephalitis: What we need to know as a NM physician.

Anti N-methyl-D-aspartate receptor encephalitis (ANMDARE), also known as limbic encephalitis (LE), is a treatable rare disorder characterized by personality changes, irritability, depression, seizures, memory loss and sometimes dementia. It is classified under paraneoplastic syndrome (PNS) and produces antibodies against NR1 and NR2 subunits of glutamate aspartate receptor. It is thought to be closely related with malignancies like small cell lung cancer, ovarian teratoma and Hodgkin's lymphoma, apart from testis, breast and rarely gastric malignancies. Non-paraneoplastic encephalitis cases are the ones with no detectable malignancy and may be triggered by severe infection. As nuclear medicine physicians, we must be aware of the diverse presentation of ANMDARE or LE and should include a whole body positron emission tomography / computed tomography (PET/CT) and not just brain PETCT during imaging. We describe the first case of PET/CT in an idiopathic ANMDARE Indian adolescent girl.

Role of positron emission tomography computed tomography in carcinoma lung evaluation.

Lung cancer has graduated from merely a reportable disease of 1912 to being the most common cause of cancer death in developed countries in recent years. The annual number of lung cancer deaths is greater than the combined cancer deaths from breast, colon and prostate. Its association with tobacco has been proved and is related to the type, amount of tobacco used, the age at initiation and duration of use. Significant advances have been made in the diagnosis and management of lung cancer over the past decade. The primary treatment of lung cancer is surgery and the best chance for a complete cure comes from the total resection of localized disease. Once nodal or distant metastases have developed, primary surgical intervention is ruled out and patient is considered for adjuvant chemotherapy with or without radiation therapy. Accurate staging and delineation of disease extent is therefore critical in the treatment planning of lung carcinoma patients. 18 F fluoro deoxy glucose (FDG) positron emission tomography (PET) has been proven to be a valuable noninvasive imaging modality in the evaluation of patients with known or suspected lung cancer and its integration with computed tomography (CT) has changed the face of PET imaging in many ways. This article will review the current role of FDG PET CT in the evaluation of pulmonary nodules, diagnosis, staging and restaging of non-small-cell lung carcinoma (NSCLC), role of PET in small cell lung Carcinoma (Ca), pleural disease and will also discuss its potential future applications.

Transient cytotoxicity of ¹³¹I beta radiation in hyperthyroid patients treated with radioactive iodine.

BACKGROUND & OBJECTIVES: Radioiodine ( 131 I) or radioactive iodine in low doses is used worldwide as the first line of management in the treatment of hyperthyroidism. Information is available on the extent and severity of cell damage after a high dose radioiodine ( 131 I) therapy for thyroid cancer, but information is scanty on its cellular effects, its extent and severity of cell damage after a low dose 131 I therapy. The present investigation was aimed to study the cytotoxic effects of a low dose 131 I therapy in varying doses as is normally being used in routine clinical practice in the treatment of various forms of hyperthyroidism. METHODS: Peripheral blood lymphocytes were analyzed in 32 hyperthyroid patients. All of them received 131 I in the form of sodium iodide solution orally. Blood lymphocytes were studied for the presence of chromosomal aberrations (CA) and micro nucleus (MN) using micronucleus assay. Blood samples of these patients were drawn prior to the treatment, on 7 th and 30 th days after the treatment. RESULTS: The results indicated a positive relationship between 131 I dose, CA and MN frequency. A statistically significant increase in CA and MN frequency in day 7 post- therapy and a decrease in mean levels of CA and MN on day 30 post-therapy were observed when compared to pre-therapy. INTERPRETATION & CONCLUSIONS: This study showed that the cytogenetic damage induced by 131 I in low doses i.e., less than 555MBq was minimal and reversible. Patients can be motivated to undertake this safe and easy procedure as a first line of therapy in the treatment of hyperthyroidism.

Staring secondaries, where is the primary?

An asymptomatic issueless young staff nurse underwent pre-employment health screening and USG abdomen showed multiple hypodense lesions in liver. Further screening with whole body positron emission tomography-computed tomography (PET-CT) scan showed significantly FDG avid mass involving most of the right lobe of liver with multiple large FDG avid lymph nodal metastases. Unsuspected focal abnormal, FDG avid, hyperdense mural nodule was seen in uterus, which is the site of primary.

Role of myocardial perfusion single photon emission computed tomography in pediatric cardiology practice.

Diagnostic and prognostic power of myocardial perfusion imaging in patients with coronary artery disease has been demonstrated with planar imaging which was further improvised with addition of gated SPECT and newer Technetium labeled myocardial perfusion tracers like SestaMIBI, Tetrofosmin. Myocardial perfusion abnormalities at rest and after stress are considered to be the best predictors of cardiac event-free survival in adults with ischemic heart disease. This article highlights various myocardial perfusion imaging (MPI) radiopharmaceuticals, exercise procedures, pharmacological stress protocols, indications for MPI and myocardial perfusion patterns in children with some of the common congenital and acquired heart diseases.

Pyrazolylcyclotriphosphazene containing pendant polymers: synthesis, characterization, and phosphate ester hydrolysis using a Cu(II)-metalated cross-linked polymeric catalyst.

A multi-pyrazolyl cyclotriphosphazene containing polymerizable group N(3)P(3)(3,5-Me(2)Pz)(5)(O-C(6)H(4)-p-C(6)H(4)-p-CH=CH(2)) (2) has been prepared from the corresponding chloro derivative N(3)P(3)Cl(5)(O-C(6)H(4)-p-C(6)H(4)-p-CH=CH(2)) (1). The X-ray structures of 1 and 2 have been determined. Compound 2 undergoes ready metalation with CuCl(2) to afford N(3)P(3)(3,5-Me(2)Pz)(5)(O-C(6)H(4)-p-C(6)H(4)-p-CH=CH(2)).CuCl(2) (3). Model compound N(3)P(3)(3,5-Me(2)Pz)(5)(O-C(6)H(4)-p-CHO).CuCl(2) (6) has been prepared and characterized by spectroscopy and X-ray crystallography. In this compound, the coordination around copper is distorted trigonal bipyramidal, and the cyclotriphosphazene coordinates in a non-gem N(3) mode. Compound 2 has been copolymerized with divinylbenzene to afford cross-linked multisite coordinating polymer CPPL which is readily metalated with CuCl(2) to afford copper-containing polymer CPPL-Cu. The coordination environment around copper in CPPL-Cu has been evaluated by obtaining its EPR, optical, and IR spectra and comparing them with those of model compounds 3 and 6. The utility of CPPL-Cu as a heterogeneous catalyst has been demonstrated in the phosphate ester hydrolysis involving three model phosphate esters: p-nitrophenyl phosphate (pNPP), bis(p-nitrophenyl) phosphate (bNPP), and 2-(hydroxypropyl)-p-nitrophenyl phosphate (hNPP). In all of these reactions, a significant rate enhancement of ester hydrolysis is observed. Detailed kinetic analyses to evaluate Michaelis-Menten parameters have also been carried out along with experiments to elucidate the effect of pH, solvent, and temperature on the rate of hydrolysis. Recycling experiments on the hydrolysis of pNPP with CPPL-Cu shows that it can be recycled several times over without affecting the rates.